Page 74 - APPENDICES for Stephen Spero

Cost Cost in Cost after
Retail Cost after
Selected drugs before coverage coverage
cost deductible
deductible gap gap

Temazepam 15mg capsule $3.17 $3.17 $3.17 $0.79 $3.17

Monthly totals $895.14 $888.07 $150.17 $222.01 $53.04

Estimated total drug + premium cost

You will pay $1,198.94 per year on drug + premium costs.
Based on current drug costs, it's estimated that:
You'll meet your $435.00 deductible in August
You'll enter the coverage gap in December
You won't exit the coverage gap

Estimated monthly drug costs

This doesn't include your monthly plan premium of $5.80.

View the costs of your drugs every month

Time period Estimated monthly drug costs
If you get your
August $482.00 prescriptions filled at
Rite Aid, your costs
September $147.00 for the last 3 months
of this year are
October $150.17 $796.57, including
your monthly drug

November $147.00 plan premiums of
$5.80 a month.

December $243.77

WALMART PHARMACY 10-2479 - Drug costs during coverage

phases

Preferred in-network pharmacy

Cost Cost in Cost after
Retail Cost after
Selected drugs before coverage coverage
cost deductible
deductible gap gap